Synthesis of acridone derivatives via heterologous expression of a plant type III polyketide synthase in Escherichia coli.

BACKGROUND: Acridone alkaloids are heterocyclic compounds that exhibit a broad-range of pharmaceutical and chemotherapeutic activities, including anticancer, antiviral, anti-inflammatory, antimalarial, and antimicrobial effects. Certain plant species such as Citrus microcarpa, Ruta graveolens, and Toddaliopsis bremekampii synthesize acridone alkaloids from anthranilate and malonyl-CoA. RESULTS: We synthesized two acridones in Escherichia coli. Acridone synthase (ACS) and anthraniloyl-CoA ligase genes were transformed into E. coli, and the synthesis of acridone was examined. To increase the levels of endogenous anthranilate, we tested several constructs expressing proteins involved in the shikimate pathway and selected the best construct. To boost the supply of malonyl-CoA, genes coding for acetyl-coenzyme A carboxylase (ACC) from Photorhabdus luminescens were overexpressed in E. coli. For the synthesis of 1,3-dihydroxy-10-methylacridone, we utilized an N-methyltransferase gene (NMT) to supply N-methylanthranilate and a new N-methylanthraniloyl-CoA ligase. After selecting the best combination of genes, approximately 17.3 mg/L of 1,3-dihydroxy-9(10H)-acridone (DHA) and 26.0 mg/L of 1,3-dihydroxy-10-methylacridone (NMA) were synthesized. CONCLUSIONS: Two bioactive acridone derivatives were synthesized by expressing type III plant polyketide synthases and other genes in E. coli, which increased the supplement of substrates. This study showed that is possible to synthesize diverse polyketides in E. coli using plant polyketide synthases.

Effects of high-frequency repetitive transcranial magnetic stimulation on reducing hemiplegic shoulder pain in patients with chronic stoke: a randomized controlled trial.

OBJECTIVE: To examine whether high-frequency (10 Hz) repetitive transcranial magnetic stimulation (rTMS), applied over the primary motor cortex of the affected hemisphere, could be used to manage hemiplegic shoulder pain (HSP). METHODS: Twenty-four chronic stroke patients with chronic HSP, randomly assigned into the rTMS group (10 sessions of high-frequency stimulation) or the sham group (sham stimulation), were performed. The Numeric Rating Scale (NRS) was used to evaluate the intensity of pain at pretreatment, and at 1 day, and 1, 2 and 4 weeks after treatment. Changes in upper-limb motor function were evaluated using the Motricity Index (MI-UL) and modified Brunnstrom Classification (MBC). RESULTS: When compared to pretreatment, the rTMS group showed a significant decrease in the NRS score at 1 day, and 1, 2 and 4 weeks after finishing rTMS sessions, with no significant change in the sham group. The NRS score after the rTMS sessions reduced by 30.1% at 1 day, 29.3% at 1 week, 28.0% at 2 weeks and 25.3% at 4 weeks. Passive shoulder range of motion, MI-UL, and MBC, however, did not significantly change in either group. CONCLUSIONS: High-frequency rTMS could be used as a safe, beneficial therapeutic tool to manage HSP. We think it can be used as an adjuvant therapeutic modality to enhance the therapeutic outcome of HSP.

A New Sacroiliac Joint Injection Technique and Its Short-Term Effect on Chronic Sacroiliac Region Pain.

OBJECTIVES: Sacroiliac joint (SIJ) injections have been used to provide short-term relief of SIJ pain. In this study, the authors investigated a new technique using a superior approach. METHODS: Twenty four patients with chronic SI joint paint were recruited. Each patient was treated with a single SIJ intra-articular injection plus a periarticular injection of local anesthetic and corticosteroid in one procedure. Technical accuracy of the intra-articular procedure was determined by having 2 independent observers review and rate the quality of arthrograms obtained. Treatment effects were evaluated using a numerical rating scale, the Oswestry disability index (ODI) and global perceived effect (GPE). RESULTS: Both independent observers agreed that satisfactory arthrograms were obtained in all patients. Pain scores and disability were significantly reduced at 2 weeks and 4 weeks after treatment. Nineteen patients (79%) reported satisfaction with treatment. No serious adverse effects were encountered. CONCLUSIONS: The superior approach consistently achieves good access to the SI joint, and achieves outcomes that are compatible with those of other techniques. The superior approach constitutes an alternative to other techniques for injections into the SI joint.

The Short-Term Outcome of Transforaminal Epidural Steroid Injection in Patients with Radicular Pain Due to Foraminal Stenosis from Lumbar Isthmic Spondylolisthesis.

Purpose: In this study, we evaluated the therapeutic outcomes of transforaminal epidural steroid injection (TFESI) in managing chronic radicular pain due to foraminal stenosis. Furthermore, we evaluated its effectiveness according to isthmic spondylolisthesis (IS) severity. Patients and Methods: We included 40 patients with radicular pain due to IS-derived foraminal stenosis in our study and treated them with TFESI. Two patients were lost during follow-up. Based on the lateral lumbar radiograph findings, we allocated the recruited patients with < 25% slippage by IS to Group 1 (n = 23) and those having 25-50% slippage to Group 2 (n = 15). The degree of pain was measured using a numeric rating scale (NRS) at pre-treatment and 1 and 2 months after TFESI. Results: In 38 patients who completed the study, the NRS at pre-treatment was significantly reduced at the 1- and 2-month follow-ups. In the Group analysis, the NRS scores were significantly reduced after TFESI in both Groups 1 and 2, regardless of IS severity. However, the reduction in NRS scores 1 month after TFESI was significantly greater in Group 1 than in Group 2. Moreover, the rate of successful treatment outcomes was significantly higher (65.2%) in Group 1 than in Group 2 (26.7%). Conclusion: After TFESI, chronic radicular pain was significantly reduced regardless of IS severity, and its effect persisted for at least 2 months. However, its effect was superior when the vertebra slippage by IS was less than 25% compared to patients with 25%-50%.

Attenuation of spinal cord injury-induced astroglial and microglial activation by repetitive transcranial magnetic stimulation in rats.

Spinal cord injury (SCI) causes not only loss of sensory and motor function below the level of injury but also chronic pain, which is difficult and challenging of the treatment. Repetitive transcranial magnetic stimulation (rTMS) to the motor cortex, of non-invasive therapeutic methods, has the motor and sensory consequences and modulates pain in SCI-patients. In the present study, we studied the effectiveness of rTMS and the relationship between the modulation of pain and the changes of neuroglial expression in the spinal cord using a rat SCI-induced pain model. Elevated expressions of Iba1 and GFAP, specific microglial and astrocyte markers, was respectively observed in dorsal and ventral horns at the L4 and L5 levels in SCI rats. But in SCI rats treated with 25 Hz rTMS for 8 weeks, these expressions were significantly reduced by about 30%. Our finding suggests that this attenuation of activation by rTMS is related to pain modulation after SCI. Therefore, rTMS might provide an alternative means of attenuating neuropathic pain below the level of SCI.

Partial isolated tear of the popliteus tendon following an in-car traffic accident: A rare cause of knee pain: A CARE-compliant case report.

RATIONALE: Lesions caused by traffic accidents are often microscopic and minimal; therefore, their diagnosis can be easily overlooked. Moreover, when it is a rarely reported type of lesion, it can be even more easily undiagnosed. Isolated popliteal injuries are uncommon and have rarely been reported. PATIENT CONCERNS: In this case study, we describe a right partially isolated popliteus tendon rupture that was undiagnosed for 2 years in a patient with posterior knee pain after an in-car traffic accident. A 49-year-old female patient presented with right knee pain that had persisted for 2 years and was initiated after an in-car traffic accident. The patient's right knee pain aggravated while standing and walking. Six months after the accident, her pain was confined to the posterolateral aspect of the knee and subsequently spread throughout her right knee. The pain score was 4 on a numerical rating scale. Physical examination revealed tenderness in the posterolateral corner of the right knee. Additionally, right knee pain was reported in the terminal range of knee flexion during the passive range of motion test. Radiographs of the right knee showed normal findings. DIAGNOSES: A T2-weighted proton density sagittal and coronal knee magnetic resonance imaging revealed a partial-thickness tear with intrasubstance ganglion cysts at the musculotendinous junction of the popliteus tendon. No other abnormalities were observed in the patient. INTERVENTION: Conservative treatment involved strengthening exercises and functional rehabilitation programs. OUTCOMES: Six months later, the knee pain almost completely subsided. LESSONS: Musculoskeletal injuries caused by traffic accidents are frequently overlooked. Therefore, a detailed examination should be conducted for an accurate diagnosis. Clinicians should consider the possibility of popliteal tendon injuries in patients with posterior knee pain.

Long-term effect of pulsed radiofrequency on chronic cervical radicular pain refractory to repeated transforaminal epidural steroid injections.

OBJECTIVE: The article aims to evaluate the long-term effectiveness and safety of pulsed radiofrequency (PRF) on the dorsal root ganglion (DRG) in patients with chronic cervical radicular pain refractory to repeated transforaminal epidural steroid injections (TFESIs). DESIGN: This is a prospective observational study. METHODS: We retrospectively reviewed data on 112 subjects who had received repeated TFESIs for cervical radicular pain. Twenty-nine of those 112 patients continued to complain of persistent cervical radicular pain, despite an average of three repeated TFESIs. Among 29 patients with sustained arm pain of over 4 on the numerical rating scale (NRS), a total of 21 patients were included prospectively. Those 21 patients underwent PRF on the symptomatic cervical DRG and were evaluated carefully for neurologic deficits and side effects. The clinical outcomes were measured via NRS for arm pain before treatment, and 1, 3, 6, and 12 months after treatment. Successful pain relief was defined as a 50% or more reduction in the NRS score as compared with the pretreatment score. After 12 months, patients' satisfaction levels with treatment were determined. RESULTS: Fourteen of the 21 patients (66.7%) after cervical PRF stimulation reported pain relief of 50% or more at the 3-month and 12-month follow-up periods, respectively. Fifteen of the 21 patients (71.4%) were satisfied with their outcome at 12 months' posttreatment. No serious adverse effects were observed. CONCLUSION: Application of PRF to the DRG appears to be an effective and relatively safe intervention technique for chronic cervical radicular pain refractory to repeated TFESIs.

Short-term Effect of Repetitive Transcranial Magnetic Stimulation on Diabetic Peripheral Neuropathic Pain.

BACKGROUND: Approximately half of the patients with long-standing diabetes are known to have diabetic peripheral neuropathy (DPN). Pain from DPN deteriorates quality of life and hinders activities of daily living. OBJECTIVES: This study aimed to evaluate the short-term effect of high-frequency (10 Hz) repetitive transcranial magnetic stimulation (rTMS) on the left primary motor cortex (M1) for neuropathic pain in the lower extremities due to DPN. STUDY DESIGN: A randomized controlled trial. SETTING: The outpatient clinic of a single academic medical center. METHODS: In this randomized trial, 22 patients with DPN were randomly assigned to the rTMS group (10 Hz stimulation, 5 sessions) or the sham group. A numeric rating scale (NRS) was used to measure pain intensity before treatment and after one day and one week of treatment. Physical and mental health status were evaluated using the Short Form 36-Item Health Survey (SF-36), comprising 2 subscales (physical and mental component scores [PCSs and MCSs]), at one-week posttreatment. Of the 22 included patients, 20 (10 patients in each group) completed the study. RESULTS: In the rTMS group, the NRS score at one day and one week posttreatment was significantly lower than that at pretreatment. The SF-36 PCS and SF-36 MCS were significantly increased one week after the rTMS sessions. However, in the sham group, the NRS score, SF-36 PCS, and SF-36 MCS did not significantly change after the rTMS sessions. LIMITATIONS: The small number of included patients and no long-term follow-up. CONCLUSION: High-frequency rTMS on the left M1 may be useful for managing pain in the lower extremities due to DPN and may improve a patient's the quality of life.

Ultrasound-guided ethyl alcohol injection to the deep branch of the ulnar nerve to relieve hand spasticity in stroke patients: A case series.

Hand spasticity with a flexor pattern is a common problem affecting stroke patients and can result in pain, contractures, esthetic concerns, skin maceration, and overall loss of function. Poststroke (≥6 months) hemiparetic adult patients having a Modified Ashworth Scale (MAS) score of ≥1 for metacarpophalangeal flexion and thumb adduction spasticity were selected to receive an ultrasound-guided 20% ethyl alcohol block performed perineurally at the level of the deep branch of the ulnar nerve. Their MAS scores were evaluated pretreatment at 1 month and the change in MAS scores was assessed using Wilcoxon's test. The threshold for statistical significance was set at p < 0.05. The mean MAS score for the flexor muscles of the 5 MCP joints and for thumb adduction was reduced from 3.3 ± 0.5 at pretreatment to 0.9 ± 0.5 at 1 month after the injection for the 10 patients. One month after the injection, the MAS scores were significantly reduced compared with those at pretreatment (p < 0.001), without complications. These are encouraging results showing that ultrasound-guided alcohol blocks of the deep branch of the ulnar nerve are safe and can help chronic stroke patients with metacarpophalangeal flexion and thumb adduction spasticity at 1 month.

Effect of high-frequency repetitive transcranial magnetic stimulation on chronic central pain after mild traumatic brain injury: A pilot study.

OBJECTIVE: Central pain can occur following traumatic brain injury, leading to poor functional recovery, limitation of activities of daily living, and decreased quality of life. The aim of this study was to determine whether high-frequency (10 Hz) repetitive transcranial magnetic stimulation, applied over the primary motor cortex of the affected hemisphere, can be used to manage chronic central pain after mild traumatic brain injury. DESIGN: Prospective randomized feasibility study. METHODS: Twelve patients with mild traumatic brain injury and chronic central pain were randomly assigned to transcranial magnetic stimulation (high-frequency stimulation, 10 sessions) or sham groups. Diffuse tensor tractography revealed partially injured spinothalamocortical tracts in all recruited patients. A numerical rating scale (NRS) was used to evaluate pain intensity during pre-treatment and immediately after the 5th transcranial magnetic stimulation session (post1), 10th transcranial magnetic stimulation session (post2), and 1 (post3), 2 (post4), and 4 weeks (post 5) after finishing treatment. Physical and mental health status were evaluated using the Short Form 36 Health Survey (SF-36), including physical and mental component scores (PCS, MCS). RESULTS: The NRS score of the repetitive transcranial magnetic stimulation group was significantly lower than the sham group score at all clinical evaluation time-points during and after transcranial magnetic stimulation sessions. The transcranial magnetic stimulation group's SF-36 PCS score was significantly higher at post2, post3, post4, and post5 compared with the sham group. CONCLUSION: High-frequency transcranial magnetic stimulation may be used to manage chronic central pain and improve quality of life in patients with mild traumatic brain injury. However, this is a pilot study and further research is needed.

Stepwise Synthesis of Quercetin Bisglycosides Using Engineered Escherichia coli.

Synthesis of flavonoid glycoside is difficult due to diverse hydroxy groups in flavonoids and sugars. As such, enzymatic synthesis or biotransformation is an approach to solve this problem. In this report, we used stepwise biotransformation to synthesize two quercetin bisglycosides (quercetin 3-O-glucuronic acid 7-O-rhamnoside [Q-GR] and quercetin 3-O-arabinose-7-O-rhamnoside [Q-AR]) because quercetin O-rhamnosides contain antiviral activity. Two sequential enzymatic reactions were required to synthesize these flavonoid glycosides. We first synthesized quercetin 3-O-glucuronic acid [Q-G], and quercetin 3-O-arabinose-[Q-A] from quercetin using E. coli harboring specific uridine diphopsphate glycosyltransferase (UGT) and genes for UDP-glucuronic acid and UDP-arabinose, respectively. With each quercetin 3-O-glycoside, rhamnosylation using E. coli harboring UGT and the gene for UDP-rhamnose was conducted. This approach resulted in the production of 44.8 mg/l Q-GR and 45.1 mg/l Q-AR. This stepwise synthesis could be applicable to synthesize various natural product derivatives in case that the final yield of product was low due to the multistep reaction in one cell or when sequential synthesis is necessary in order to reduce the synthesis of byproducts.

Refractory duodenal Crohn's disease successfully treated with infliximab.

Crohn's disease (CD) may involve any part of the gastrointestinal tract, from the mouth to the anus. Approximately >90% of cases occur in the small bowel and colon. Upper gastrointestinal involvement, especially duodenal manifestation, is relatively rare. Therefore, adequate medical treatment for duodenal CD has not yet been established. We report a case of CD with duodenal involvement. A 46-year-old man with Crohn's ileocolitis presented to our hospital with right upper quadrant pain. An endoscopy showed a deep excavated ulcer with deformity at the duodenal bulb, and he was initially treated with azathioprine (1 mg/kg), Pentasa (3.0 g/day), and a proton pump inhibitor for 1 year. However, the deep ulcer did not heal. Therefore, infliximab infusion therapy was initiated, and the duodenal lesion completely resolved on follow-up esophagogastroduodenoscopy. We report a case of duodenal CD that completely resolved following infliximab infusion, with a review of the literature.

Erratum: the effects of bronchiectasis on asthma exacerbation.

[This corrects the article on p. 209 in vol. 77, PMID: 25473408.].

The effects of bronchiectasis on asthma exacerbation.

BACKGROUND: Bronchiectasis and asthma are different in many respects, but some patients have both conditions. Studies assessing the effect of bronchiectasis on asthma exacerbation are rare. The aim of this study is to investigate the effect of bronchiectasis on asthma exacerbation. METHODS: We enrolled 2,270 asthma patients who were followed up in our hospital. Fifty patients had bronchiectasis and asthma. We selected fifty age- and sex-matched controls from the 2,220 asthma patients without bronchiectasis, and assessed asthma exacerbation and its severity based on the annual incidence of total asthma exacerbation, annual prevalence of steroid use, and frequency of emergency room visits and hospitalizations due to asthma exacerbation in each group. RESULTS: Fifty patients (2.2%) had bronchiectasis and asthma. The annual incidence of asthma exacerbation was higher in patients with asthma and bronchiectasis than in patients with asthma alone (1.08±1.68 vs. 0.35±0.42, p=0.004). The annual prevalence of steroid use (0.9±1.54 vs. 0.26±0.36, p=0.006) and the frequency of emergency room visits (0.46±0.84 vs. 0.02±0.13, p=0.001) due to asthma exacerbation were also higher in patients with asthma and bronchiectasis than in patients with asthma alone. CONCLUSION: Bronchiectasis is associated with difficult asthma control.

Classification of cause of motor weakness in traumatic brain injury using diffusion tensor imaging.

BACKGROUND: Many studies have attempted to elucidate the causes of motor weakness in patients with traumatic brain injury (TBI). Most of these studies have focused on the specific cause of motor weakness. However, little is known about the classification and elucidation of the causes of motor weakness in consecutive patients with TBI. OBJECTIVE: To attempt to classify with diffusion tensor imaging the causes of motor weakness in patients with TBI by conducting an analysis of the injury mechanism of the corticospinal tract (CST). DESIGN: Retrospective study. SETTING: Rehabilitation department of a university hospital. Patients  We recruited 41 consecutive patients who showed motor weakness among patients with TBI admitted for rehabilitation. MAIN OUTCOME MEASURES: We classified the causes of weakness according to the injury mechanism of the CST on diffusion tensor imaging. RESULTS: Injury mechanisms of the CST were classified as follows, in order: diffuse axonal injury, 24 patients (58.5%); traumatic intracerebral hemorrhage, 9 patients (21.9%); transtentorial herniation, 6 patients (14.6%); and focal cortical contusion, 4 patients (9.8%). In patients with diffuse axonal injury, the mean number of lesions composing CST injury was 3.6 (range, 2-6) and CST injury locations were as follows: the pons (61%), the cerebral peduncle (50%), the medulla (40%), the posterior limb of the internal capsule (17%), and the corona radiata (13%). CONCLUSION: We found that diffusion tensor imaging was useful in elucidation and classification of the causes of motor weakness resulting from CST injury in patients with TBI.

Relation of absolute or relative adiposity to insulin resistance, retinol binding protein-4, leptin, and adiponectin in type 2 diabetes.

BACKGROUND: Central fat mass (CFM) correlates with insulin resistance and increases the risk of type 2 diabetes and cardiovascular complications; however, peripheral fat mass (PFM) is associated with insulin sensitivity. The aim of this study was to investigate the relation of absolute and relative regional adiposity to insulin resistance index and adipokines in type 2 diabetes. METHODS: Total of 83 overweighted-Korean women with type 2 diabetes were enrolled, and rate constants for plasma glucose disappearance (K(ITT)) and serum adipokines, such as retinol binding protein-4 (RBP4), leptin, and adiponectin, were measured. Using dual X-ray absorptiometry, trunk fat mass (in kilograms) was defined as CFM, sum of fat mass on the lower extremities (in kilograms) as PFM, and sum of CFM and PFM as total fat mass (TFM). PFM/TFM ratio, CFM/TFM ratio, and PFM/CFM ratio were defined as relative adiposity. RESULTS: Median age was 55.9 years, mean body mass index 27.2 kg/m(2), and mean HbA1c level 7.12±0.84%. K(ITT) was positively associated with PMF/TFM ratio, PMF/CFM ratio, and negatively with CFM/TFM ratio, but was not associated with TFM, PFM, or CFM. RBP4 levels also had a significant relationship with PMF/TFM ratio and PMF/CFM ratio. Adiponectin, leptin, and apolipoprotein A levels were related to absolute adiposity, while only adiponectin to relative adiposity. In correlation analysis, K(ITT) in type 2 diabetes was positively related with HbA1c, fasting glucose, RBP4, and free fatty acid. CONCLUSION: These results suggest that increased relative amount of peripheral fat mass may aggravate insulin resistance in type 2 diabetes.

Short-term effects of pulsed radiofrequency on chronic refractory cervical radicular pain.

OBJECTIVE: To evaluate the short-term effectiveness of pulsed radiofrequency on the dorsal root ganglion (DRG) in patients with chronic refractory cervical radicular pain. METHOD: Fifteen patients (13 males, 2 females; mean age, 55.9 years) with chronic radicular pain due to cervical disc herniation or foraminal stenosis refractory to active rehabilitative management, including transforaminal cervical epidural steroid injection and exercise, were selected. All patients received pulsed radiofrequency on the symptomatic cervical dorsal root ganglion and were carefully evaluated for neurologic deficits and side effects. The clinical outcomes were measured using a visual analogue scale (VAS) and a neck disability index (NDI) before treatment, one and three months after treatment. Successful pain relief was defined as a 50% or greater reduction in the VAS score as compared with the pre-treatment score. After three months, we categorized the patients' satisfaction. RESULTS: The average VAS for radicular pain was reduced significantly from 5.3 at pretreatment to 2.5 at 3 months post-treatment (p<0.05). Eleven of 15 patients (77.3%) after cervical pulsed RF stimulation reported pain relief of 50% or more at the 3 month follow-up. The average NDI was significantly reduced from 44.0% at pretreatment to 35.8% 3 months post-treatment (p<0.05). At 3 months post-treatment, eleven of fifteen patients (73.3%) were satisfied with their status. No adverse effects were observed. CONCLUSION: The results demonstrate that the application of pulsed radiofrequency on DRG might be an effective short-term intervention for chronic refractory cervical radicular pain. Further studies, including a randomized controlled trial with long-term follow-up, are now needed.